Andersons pediatric cardiology 362
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FIG.16.5 Transversethoracosternotomy.Theskinandsubcutaneous
tissuesaredividedwithacombinationoftheknifeandelectrocauteryalong
thesolidlineasindicated.Asubcutaneousflapbeneaththebreasttissueis
developeduntilthefourthorfifthintercostalspaceisreached.The
intercostalsarethendividedatthedesiredinterspace(dashedline).The
internalmammaryarteriesareidentifiedandligated.Thesternumisthen
dividedtransverselyattheinterspaceinwhichthethoraciccavitieswere
entered.
TheanterolateralthoracotomyisshowninFig.16.6.Therightanterolateral
thoracotomyhasbeenusedforrepairofavarietyofcongenitalcardiac
malformations,withgoodresults.35–40Theanterolateralthoracotomycanbe
placedinthemammarycreaseandhasbeenusedasanalternate,more
cosmeticallyappealingapproachforsimpleintracardiacoperationssuchas
closureofatrialseptaldefects.41Therehavebeenisolatedreports,however,of
compromisedorasymmetricdevelopmentofthebreastwiththisincision,42,43
andofincreasedpain.44Theleftanterolateralthoracotomyisoftenusedonthe
hemodynamicallyunstablevictimofthoracictraumawithsuspecteddamageto
thethoracicstructures.Ifsufficientaccessisnotpossiblewiththisincision,it
canbeextendedacrossthemidlineforfurtheraccesstocardiacstructures.
FIG.16.6 Anterolateralthoracotomy.Theskinandsubcutaneoustissues
aredividedwithacombinationoftheknifeandelectrocauteryalongtheline
indicated.Insomeindividuals,itisnecessarytodevelopaflapbeneaththe
subcutaneoustissuetoreachthedesiredintercostalspace.Thepectoralis
majorandtheintercostalmusclesinthedesiredspaceofentryarethen
divided.Insomeindividuals,theskinincisioncanbemademorelaterally,
avoidingdivisionofthepectoralismajor.
MinimallyInvasiveApproaches
Incontinuedattemptstoimprovethecosmeticresultsaftersurgery,avarietyof
minimallyinvasivetechniqueshaveemerged.Originallyappliedtoadults,they
arenowfrequentlyappliedtochildren.Amongthesetechniquesarepartialupper
andlowersternotomy,video-assistedthoracoscopicsurgery,theminithoracotomy,thesubxiphoidapproachtotheheart,androbotictechniques.45–48
Useofthesetechniquesiscontroversial.Opponentscitethepotentialfor
compromisedexposure,andtheaccompanyingincreasedriskoftheprocedure.
Proponentscitethepsychosocialbenefitsofsmallerincisions.Thepotentialfor
limitedexposuremustbebalancedagainstthecomplexityofthecase,andthe
likelihoodoffuturereoperation.Partialsternotomiescanconsistofapartial
superiorsternotomyorapartialinferiorsternotomy.Thepartialupper
sternotomyhasbeenusedforsuchcomplexproceduresasthearterialswitch
operation.49Theinferiorpartialsternotomyhasbeencommonlyusedformany
yearsforproceduressuchasplacementofepicardialpacemakerleads,where
accesstotheanteriorportionoftheheartoratriumisneeded.Atrialseptal
defectshavebeenrepairedthroughthisincision.50Morerecently,abroader
rangeofcardiacoperationshavebeenperformedthroughthisincisionincluding
closureofventricularseptaldefects,repairoftetralogyofFallotand
atrioventricularseptaldefectwithcommonjunction,andproceduresonthe
mitralvalve.49–53Insmallchildrenwithmorepliablesternums,asimilarvariety
ofprocedureshasbeenaccomplishedthroughasubxiphoidincision.54The
verticalinfra-axillarythoracotomyhasalsobeenreportedasaminimally
invasivealternativetomediansternotomyforclosureofatrialseptaldefects.In
additiontothecosmeticresult,theriskofinjurytodevelopingbreasttissuein
femalepatientsisavoidedwiththisapproach.55
Video-assistedthoracicsurgeryhasbecomeamainstayofgeneralthoracic
surgeryduringthelastdecade.Inthistypeofprocedure,onelargeincisionis
replacedbytwotofoursmallerincisions(Fig.16.7).Athoracoscopeisplaced
throughoneincision.Otherportsareusedtoplacestaplingdevices,
thoracoscopicscissors,orinstrumentsfordissectionandretraction.The
techniquehasbeenusedforligationofthearterialduct,closureofinteratrial
communications,anddivisionofvascularrings.55–59Insomeseries,painand
postoperativestayaresignificantlyreduced.60–64Whenusedforclosureof
interatrialcommunicationsinadultpatients,video-assistedthoracoscopic
surgeryhasbeenshowntobesafe,withashorterlengthofintensivecareunit
staycomparedtofullopensternotomy.65Themajorityofadultpatients(more
than60%)undergoingthistechniqueforinteratrialcommunicationsclosureare
extubatedintheoperatingroom.65Inpediatrics,video-assistedthoracoscopic
surgeryhasbeenpredominantlyemployedfordivisionofvascularrings.Ina
largesingleinstitutionseriesover25years,thereseemedtobewaning
enthusiasmforthisapproachinthemorecontemporarysurgicalera.66Thislack
ofenthusiasmmayberelatedtotheriskoflife-threatening,difficult-to-control
bleedinginpatientswithapatentdoubleaorticarch.67
